Tag Archives: Health care

Can we find the spirit of ’45 in 2013?

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

Screen Shot 2013-04-01 at 18.33.01

The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

What’s in a name?

At work recently I felt like a broken record. “What’s their name?” I said again and again with increasing frustration as I received calls about patients who were referred to as “bed 3,” “side room 1,” and “bed 9.”

Of course, at times it is convenient and even desirable to omit a patient’s name in a conversation. It was suggested on Twitter that it may be better to overhear what ‘bed 9’ needs rather than ‘John Doe is ready for his haemorrhoidectomy,’ and in this case I agree! My worry is that in most cases there is no explicit intent to maintain confidentiality. Instead the convenience of referring to people by their bed number slips into routine communication. I have certainly been guilty of this myself. I worry that this is not merely disrespectful, but that it contributes to the dehumanising experience of being a patient, and negatively impacts on the doctor-patient relationship.

There are many factors that contribute to dehumanisation in hospitals. It is often not the fault of individuals, and I would certainly not suggest any of the nurses I work with are uncaring. Instead the environment and structures inherent in the way we work create an “us and them” divide where healthcare workers and patients are in different tribes. This extends to factors as simple as the clothes we wear, an example of “deindividuation.” I am always amazed by the dramatic transformation when a patient puts on their own clothes as they get ready to leave hospital, having previously only worn a generic hospital gown. They miraculously turn into a “person” rather than a “patient.”

Image from: http://healthland.time.com/2010/02/09/designing-a-glamorous-hospital-gown/

The design of hospital gowns is practical but does not enhance dignity

A recent paper by Haque and Waytz “Dehumanisation in medicine: causes, solutions and functions” explores this idea further, identifying a number of contributing factors, considering simple solutions, and also exploring examples of necessary and unnecessary dehumanisation. An example of necessary dehumanisation is that it reduces physician burnout: if I felt the same intensity of empathy for every patient undergoing a blood test as a typical non-healthcare worker would, I would be overwhelmed and unable to do my job. But there are many examples of unnecessary dehumanisation that we should identify, expose and address to ensure they do not affect how we think of, and care for, our patients.

Although as individuals we may aspire to a partnership model with our patients, our structures rarely facilitate this, and there is a danger that we see patients not as individuals but as tasks to be ticked off. I am much less personally interested that “bed 9 needs a cannula,” than I am that “Eve’s cannula has tissued again and she really needs her iv fluids.” And when I think about constructing a management plan, I am much less likely to take the time to explain my clinical reasoning and involve the patient in decision making if I think of him as “the PE in bed 3″ rather than “Bob, the lovely history teacher who has a PE.”

If and when I become a patient I want my medical team to treat my as an individual, consider my personal context and experience of illness, and integrate this into their decision-making process. I do not want to be referred to as “bed 2.” I realise that as a Medical Reg I would embody ‘the nightmare patient’, but something approaching this true partnership model should be what we aspire to for every patient, not just those (like me) who explicitly demand it. Many things need to change to achieve this ideal including; better data sharing with, and ownership by patients; better public and patient education allowing valuable discussion about trial data and the value and limits of evidence-based medicine; and a dramatic change in our IT structures such that they enhance rather than impede communication across arbitrary boundaries of primary, secondary  and tertiary care.

We should work to achieve system changes, but they will take time to implement. We can take immediate personal responsibility for our own actions and our own role in dehumanisation in healthcare.

A statement in Haque and Waytz’ paper that particularly hit home was:

“Medical education and training should also incorporate practices that allow physicians to emphasize the common humanity they share with their patients, specifically their shared mortality; illness narratives; and vulnerability to disability, suffering, personal loss, and other forms of uncertainty”

I am a passionate advocate for a strong educational focus on our common humanity, and for the power in sharing personal narratives, thoughts and uncertainties as professionals with the aim of demystifying and disempowering the role of “the health professional.”  I suppose that is one aspect of what this blog has tried to achieve. By sharing my personal experiences and exposing my doubts and flaws I hope to show the human side of my role as a doctor.

I have been inspired by NHS Change Day to consider what small changes I can make in my own practice that will improve the lives of my patients. I will be pledging to re-humanise my personal practice of medicine, by always using patients names as a constant reminder of their individuality. I hope that hearing  “bed 9 wants to see you” will become the exception rather than the rule. You can make this happen. Pledge with me

NHS Change Day

When the lights go out

Most people I know have never watched a person die. Even those that have been to funerals and therefore have seen and been in physical proximity to a body, have rarely been present at the moment of death. The moment when in the eyes of the dying person the lights go out.

I have been there, in the moment, a number of times and remember every time with eerie clarity. Sometimes I have known the patient well; other times I have only met them in their last minutes or seconds. Sometimes it has been almost ethereally peaceful. Other times it has been frantic, chaotic or distressing despite our best efforts to treat end of life symptoms. Most often it has just happened.

Jean* had been admitted from her nursing home with end-stage dementia and multi-organ failure and was clearly in the last hours of life when she arrived in the emergency department. I admitted her in the morning and was passing through the medical assessment unit a few hours later and felt the need to pop in and make sure she was comfortable. There was a stillness in her room that felt anticipatory. I offered to stay whilst the healthcare assistant went to attend to another patient and so happened to be sat by Jean’s bed when she died. She was calm and comfortable. When the moment came it felt like the world paused for a moment and held its breath, while she held hers, then exhaled as she breathed her last breath.

And then the world continued on, with one less person in it.

Each time I have had this experience I have felt the same incredulity at the enormity of the moment. Whether I apply a philosophical or a religious framework, I struggle to grasp what happens when everything that makes up the person; their memories, actions, impact, emotions, beliefs are suddenly gone. The contrast between the significance of the event, and the undramatic way it often occurs, never fails to astound me.

When I know that one of my patients is dying I always feel an urge to check on them rather more often than is clinically necessary. Somehow I feel a responsibility to make sure they are not alone for the final moment. I know that many nurses share this feeling, but I sometimes wonder who we are really there for. Are we fulfilling an unwritten societal contract that means we must ensure no individual has to face the abyss alone; or are we, the living, reasserting our own vitality by forcing ourselves into close proximity with death?  I know many nurses who, whether religious or not, still insist on opening the window after a patient has died to “let the soul out,” as part of a ritual ingrained in them during their training. Even the confirmation of death by a doctor, which mandates checking pupil reactions, palpating for the pulse, and listening for heart and breath sounds, feels part of the ritual. In a busy shift this necessary pause feels appropriate to mark the fact that the world has lost another individual. The need for ritual at the end of live is pervasive across ages and cultures, but in an era of high expectations of healthcare we seem to struggle more with the inevitable than ever before.

“For the love of God,” Damian Hirst

We need a greater acceptance of the body’s physical frailty and a more realistic view of the limits of medical intervention. We need to find a more tangible connection with all stages of the circle of life, despite our sanitised and secularised society. We need to embrace the fact that the inevitability of our own mortality sets us free to live in the moment. As Wittgenstein noted “eternal life belongs to those who live in the present.”

I intend to make every day I have left count, before the lights go out.